Provider Demographics
NPI:1922167709
Name:FINE, SALLY W (LIMHP, MSW, MA)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:W
Last Name:FINE
Suffix:
Gender:F
Credentials:LIMHP, MSW, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2520 S 98TH AVE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124-1910
Mailing Address - Country:US
Mailing Address - Phone:402-391-0589
Mailing Address - Fax:
Practice Address - Street 1:11414 W CENTER RD
Practice Address - Street 2:SUITE 220
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-4487
Practice Address - Country:US
Practice Address - Phone:402-330-4014
Practice Address - Fax:402-334-2930
Is Sole Proprietor?:No
Enumeration Date:2006-12-07
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE769101YM0800X
NE791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE82383OtherBLUE CROSS BLUE SHIELD
NE238567OtherMIDLANDS CHOICE
NE47068631113Medicaid